Peer Learning Group 2 (November 2010)

8/8/2019 Peer Learning Group 2 (November 2010)

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HRSA State Health Access ProgramPeer Learning Group 2: Benefit Design

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STATE HEALTH ACCESS PROGRAM:Peer Learning Group 2

Benefit Design

Supported by the Health Resources and Services Administration

Thursday, November 18, 2010This event will begin at 2:00pm Eastern

Please hold until Anne Gauthier starts the conferenceThe audio portion of this web event can be accessed by dialing

866.740.1260Access Code: 5077588

*6 to Mute* 7 to Unmute


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Todays Agenda

2:00-2:05 Introduction and Roll Call (Anne Gauthier, NASHP)

2:05-2:40States are invited to briefly update on benefit design issuesrelated to their SHAP grants and new provisions for the ACA.

Auto-assigned states: ME, MN, NC, OR, TX, VA, WA, WI, WV

2:40-3:10 Presentation from Jeanene Smith in Oregon about value-basedinsurance design

3:10-3:15 Final Questions and Wrap Up


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Benefit Design:State Updates


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State Spotlight: Oregon


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Oregon s Value-Based Essential BenefitPackage

& Initial Pricing Estimates

Jeanene Smith, MD, MPHOffice for Oregon Health Policy and Research

November 2010


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Typical Insurance Benefit Package Design

Portion a person pays (cost-sharing) is applied:By specific service orBy the location wherethe service is providedMay tier prescriptiondrugs by generic versusbrand name

Service

HMO-type

plan

PPO-type

planH ospital $50/day up

to $250/stay15%

coinsurance

Office Visit $5-$20copay

15%coinsurance

Ambulance $75 copay 15%coinsurance

EmergencyRoom

$75 copay 15%coinsurance


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Value-Based Essential Benefits Package(VBEBP)

Value-based services, basic diagnostic, comfort care No/low cost share For prevention/chronic disease management

Tiered coinsurance based on best evidence

Goal is to steer patients towards more valuable and cost-effective services

Evidence-based drug formulary


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20 Sets of Value-Based Services in the EssentialBenefit Package

Value-based services are medications, tests, or treatments thatare highly effective, low cost, and have a lot of evidencesupporting their use

Most of these services should be provided via outpatient care ideally in a patient-centered primary care home

These services should be offered at NO cost to patients (nocopays or coinsurance) in order to encourage use of theseservices given their high level of benefit

Goal: Have these services used as much as possible


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VBEBP sT iered Benefits for Other Services:Cost Sharing Applied Based On Best Evidence

T ier I :Lower cost shareH

ighly effective care for severe chronicdisease and life-threatening illness & injuryExamples:

Emergent dental careH ead injuriesAppendicitisH eart attackThird degree burnsKidney failureRheumatoid arthritisLow birth weight

T ier II:Next level of cost share

Effective care of other chronic diseaseand life-threatening illness & injuryExamples:

Breast cancerBladder infectionsCOPD/emphysemaMultiple sclerosisPost-Traumatic Stress DisorderAttention Deficit DisorderEpilepsyGlaucoma


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VBEBP sT iered Benefits:Cost Sharing Applied Based On Best Evidence

T ier III:3 rd level of cost shareEffective care for non-life-threatening

illness & injuryExamples:

Broken armEar/sinus infectionsDenturesKidney stonesH

erniated diskRefluxMigrainesFibroidsCataractsObsessive-Compulsive Disorder

T ier IV:Highest level of cost shareLess effective care and care for self-

limited illness and minor illness & injuryExamples:

ColdChronic low back painSprained ankleCracked rib

Seasonal allergiesAcneViral sore throatTension headacheDental implantsLiver transplant for cancer


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How The VBEBP ComparesOregon s Health Leadership

Council s DesignVBEBP

Categories WithNo Cost Share

T ier 1

Tests and treatments for six chronicdiseases (asthma, CAD, C H F, COPD,depression, diabetes)Annual exam & Preventive screeningsImmunizations

Value-Based Services

Same plus coverage for 14 additionalconditions/chronic diseases (e.g.,ETOH Tx, bipolar Dz, H TN, lipids,maternity/newborn)Basic diagnostics & Comfort care

Next Level (s) of Cost- sharing

T ier 2

Standard medical product design Portion of hospital services Portion of outpatient services Portion of Emergency Room cost

T iers I-III

Encourages care in primary careTiered cost sharing bycondition/associated service basedon evidence

Highest CostSharing or NotCovered

T ier 3H ave higher cost sharing

Preference sensitive treatmentsComplex outpatient imaging

Excluded Services

T ier IV less effective/self-limitingOther

Excluded conditions (no coverage)Discretionary Services (separatebenefit limit)


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Preliminary Actuarial Analysis

Using earlier model developed for initial EBP design

based on Medicaid dataApplied for first time to commercial dataOEBB claims data from ODS plansOH A/DH S Actuarial Services Unit significant

programming and data handlingAnalysis begins with ODS 200 9 claims


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Preliminary Actuarial Analysis (2)

Costs are trended to 2010

Categorizing four tiers relatively straightforwardJudgment, rules of thumb, and many assumptions totease out first estimates for value-based services, 2 visitsper year, diagnostic servicesMacro comparison of 4 Plan Designs ODS Plan 7 (200 9 ) baseline ODS Plan 7 (2010), H ealth Leadership Council, Value Based

Essential Benefits Package


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Asthma as a Value-Based Service

-15%

-10%

-5%

0%

5%

10%

15%

20%

25%

30%

35%

40%

% Change

Ma in tenan ceRX Poss e ssio n ER Use Hospit a liza tions


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Asthma as a Value-Based Service(In Terms of Cost)

Overall cost goes down $0.29 P MPM

Cost to plan goes up $1.11 P MPM

Member saves (on average) $1.40

Members with asthma save (on average) $14.00 per month out-of-pocket


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Actuarial Analysis Assumptions, Approach,Qualifiers

All work is based on PMPM costs, separate utilization

and unit costs were not availableSome copays were converted to coinsurance for pricingCollaboration effort to ballpark impacts of plan design especially on value based services (room for additionalresearch and improvement)This version includes medical and Rx, but not vision ordental


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Example Used: OEBB Plan 7Medical has $500 deductible/$2,500 OOP max20% coinsurance for most other servicesPreventive services have no cost sharingDrug has $1,000 OOP max$5 copay for generic, $25 copay for preferred brand, 50% copayfor nonpreferredStarting with 2010-2011 added some value-based features added additional cost tier ($500 copays for certain procedures) added $100 copays for sleep studies, MRI, PET scans , CT scans No incentive tier like some of the other OEBB plans Rx value copay level added ($4/$ 8 instead of flat $5)


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Example Used: HLC Version of OEBB Plan 7

Begin with OEBB 2009 planAdd 6 Value Based ServicesAdd Preference Sensitive Tier


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Example Used: VBEBP Version of Plan 7

Medical $500 deductible, $2,500 OOP

Rx separate $1,000 OOPValue based services, 2 visits, comfort care at 0%Tiered coinsurance 10%/20%/30%/50%

Tiered coinsurance 0%/20%/50% for diagnosticRX plan $0/$5/$25/50% with shared $1,000 OOP


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Preliminary PMPM Cost Comparison

$-

$50

$100

$150

$200

$250

$300

$350

$400

2009 2010

OEBB 7 2009

OEBB 7 2010

HLC

VBEBP


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Preliminary PMPM Cost Comparison

$ 00

$ 50

$400

$450

$500

$550

$600

2009 2010 2011 2012 201 2014

O EBB 7O EBB 7

L

VBEB P


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Let s ReviewAll these plan designs are making efforts to encouragethe best care, and discourage ineffective careCarrots are more expensive than sticks and savings calculations are more challenging

VBEBP has largest spread between the best and the

rest and so is a way to dampen across-the-board cuts


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G oing ForwardIf the VBEBP concepts are attractive

more work on each VBS to weigh costs and savingsof each intervention additional modeling work to tighten up all aspects and, of course, continue work with all stakeholders


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Focus G roup Progress Report

Conducting focus groups for insurers, providers,large and small employers, consumers (insured and

uninsured)Conducting in Portland, Southern Oregon, CentralOregon and Eastern Oregon as well as onlineH olding 15 in-person focus groups and 4 onlinediscussions. Groups are mostly complete.Results will be available for the November meeting


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VBEBP: SummaryFurthers Oregon s Triple Aim Improves health without increasing overall costs

Improves quality by encouraging most effective services Controls costs by discouraging less effective servicesPreliminary analysis suggests an impact on costcurveAnalysis of longer term impact will continueVBEBP offers a way to soften the impact of budgetcost sharing increasesIn an exchange, VBEBP would ensure that moremoney is steered toward higher-value care


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Questions?


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MaxEnroll: Self-Assessment Toolkit Launch! Thursday November 18, 2010 4:00pm ES T

SHAP National Webinar: S tate-to-State Exchange on HealthInsurance Exchanges

Monday November 22, 2010 1:30pm EST

Next PLG: Enrollment and retention

Tuesday December 7, 2010 2:00 pm EST

All-Grantee MeetingWashington, DC, January 12-1 3 , 2010

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Save the Date!


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Thank You!

Anne Gauthier Sonya Schwartz Kathy WitgertSenior Fellow Program Director Program [email protected] [email protected] [email protected]

Chris Cantrell Christina MillerResearch Assistant Research [email protected] [email protected]

NASHP s SHAPTeamP lease feel free to contact us with any questions.

www.nashp.org

Peer Learning Group 2 (November 2010)

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Transcript of Peer Learning Group 2 (November 2010)